Passive Care of Ear Fluid in Children OK

Children with persistent fluid build-up in their ears--an extremely common condition that can lead to chronic infections and temporary hearing loss--first should be treated with “watchful waiting,” rather than more aggressive treatments such as antibiotics or surgery, a federal panel said Thursday.

Otitis media with effusion often can disappear by itself and should not be treated until it has lasted at least three months, said a committee of outside experts convened by the Agency for Health Care Policy and Research, a part of the U.S. Public Health Service.

This recommendation “should be good news for parents,” said Dr. Philip R. Lee, assistant secretary for health. The agency’s recommendations are widely disseminated and considered the standard of care for the nation’s physicians.

After common viral infections--such as colds--and well-baby visits, ear problems in young children are the most frequent reason for trips to the pediatrician.

In 1990, there were 24.5 million pediatrician visits for all types of ear problems, and the panel estimated that otitis media with effusion accounted for as much as 35% of them, or up to 8.5 million visits.

Pediatric ear problems also add at least $2 billion to the nation’s annual health care bill, a figure that includes visits to doctors, surgery, drugs and diagnostic tests associated with hearing and speech.

Ear fluid accumulation is not life-threatening, nor does it hurt, but it can become extremely painful when infections develop, and--because it so often muffles hearing--can affect speech and language development in children between the ages of 1 and 3.

“Three months is a short period of time but it is often long enough to clear up the condition,” said Dr. Alfred O. Berg, a professor of family medicine at the University of Washington in Seattle, co-chairman of the panel. “With most of the children I see with this condition in my practice, in two or three months, it’s gone.”

Otitis media with effusion, also known as “glue ear,” is characterized by the presence of watery or mucous-like fluid behind the eardrum, which separates the outer ear from the middle ear.

It differs from acute otitis media--the common ear infection--because there are no obvious symptoms, such as a bulging ear drum, pain or fever. But “glue ear” often leads to infections.

Ear infections are caused by bacteria that migrate to the middle ear--often as secondary infections to colds--and, when fluid is present, find the dark, warm and moist environment an ideal place to breed.

Fluid is produced in all of the body’s membranes--including those in the middle ear--and usually is naturally reabsorbed within the body. Normally, the middle ear is filled with air because fluid produced there drains down through the Eustachian tube, a tiny channel that connects the middle ear to the back of the throat.

Many experts believe that otitis media with effusion occurs frequently in children because their Eustachian tubes tend to be shorter, narrower and more horizontal than those of adults, and fluid fails to drain properly. Most children outgrow the condition by the age of 6, or by the onset of puberty.

The new guidelines recommend that children undergo a hearing evaluation if the condition has not cleared after three months. If tests indicate a mild-to-moderate hearing loss in both ears, physicians should consider antibiotics--which helps eliminate the fluid in a small number of children--or surgery, the panel said.

Should the condition continue for four to six months, with hearing loss, the preferred treatment is surgery, the panel said.

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The surgical procedure, known as myringotomy, lances the eardrum to drain the fluid. At the same time, the surgeon inserts tympanostomy tubes in each eardrum. The tiny tubes provide ventilation--enabling air to reach the middle ear--thus preventing fluid from accumulating.

Such treatments, however, are not without risk.

Antibiotics can cause side effects, such as gastrointestinal problems or skin rashes, and can contribute to the growth of antibiotic-resistant strains of bacteria.

The surgery, which takes only about 20 minutes, must be performed under general anesthesia because the child must remain absolutely still. Also, the tubes naturally work their way out of the eardrum, usually within a year, and may have to be replaced--requiring repeat surgery--if the child has not outgrown the problem.

As long as the tubes remain in the eardrum, the ears must be kept dry, since water carries bacteria and can cause further infections if it enters the middle ear through the opening in the tubes. Thus, children with ear tubes must always wear earplugs or other protection when bathing or swimming.

Finally, in rare instances, the procedure can result in permanent scarring of the eardrum.

The panel recommended against other types of surgeries--removal of tonsils or adenoids--to cure the condition. It also recommended against the use of steroids, antihistamines or decongestants.